The pain gap: Women (still) aren't taken seriously by doctors — and it's killing us

"I'm obsessed now with just hearing women's doctor stories," says Anushay Hossain. "Everyone has one."

The author of "The Pain Gap: How Sexism and Racism in Healthcare Kill Women" definitely has her own. After growing up in Bangladesh, the writer, podcaster and policy analyst felt "relieved" to be delivering her baby in the nation with "the best healthcare in the world." Instead, she almost died in childbirth, an experience that left her shocked at how ineptly her medical team had handled her pain and symptoms — and how uncharacteristically compliant she'd been in her vulnerability.

This article first appeared on Salon.

It was an ordeal that led Hossain to delve into the ways in which women are treated (and mistreated) in the American health care system, and "how misogyny in medical practice profoundly impacts women's health."

As she reveals, it's not about that one insensitive, inattentive doctor here and there. It's about the institutionalized forces that deeply influence how we treat heart disease, chronic pain, COVID, and every other physical condition that impacts women's health.

Salon talked to Hossain recently about why these inequities persist, why they're even more glaring for women of color — and what we can do, systemically and individually — to close the pain gap.

This conversation has been lightly edited and condensed for clarity.

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We cannot ever truly know what someone else's pain is. But you start out very early talking about pain that is unique to women.

Gabrielle Jackson, the author of "Pain and Prejudice," said something so true, which is women's that pain is at once expected and denied. It's like they expect us to have this really high threshold, but then they don't believe us when we say that we're in pain. What else is really interesting is that in addition to the pain gap, there's a credibility gap. There's a knowledge gap. Women don't have any credibility, and it's not just about pain. It's about our health. It's about our bodies. It's amazing what women don't talk about, and the stories they keep to themselves.

Where does that come from? Does it come from the fact that we're just so used to dealing with a patriarchal system regardless of who is working in healthcare, regardless of the number of women who are doctors, because the system is still patriarchal inherently?

I don't feel like the onus should be on women, obviously. But then there is a lot that we can do and a lot of things that are changing. I grew up in Bangladesh and I was just taught, you just never question the doctor. You definitely don't question a white man. Even after 25 years in America, the power balance is so off. This is not an anti-doctor, anti-medical establishment book. But I never knew that you have choices and that you can literally deny anything, refuse anything that you want, and you can switch doctors. You don't have to stick with them.

Another interesting thing that I've seen with women is we really do try to be the perfect patient. A good student, the perfect mother.

We want to be good at being sick.

We approach our healthcare as though the most important person in that team is the doctor. But your healthcare is actually a team effort, and the most important member of that team is you. And we never give ourselves that authority. We will say, "I feel like this," and the doctor will be like, "Oh, it's probably in your head." And most women are like, "okay, maybe."

Almost every woman has been told that it's all in her head or she's imagining it, and almost every woman was never imagining it. It was almost always something like endometriosis or cancer. This is another thing I would really like to just make as a public service announcement. Women are not going to the hospital or to the doctor and just making stuff up. I'm sure there's the odd one off, but most of the time, by the time we're at the hospital or at the doctor's office, we're not there to just make crap up and waste everyone's time. We have a lot to do. We're really busy. We really don't have the time to just like go to the hospital, make some s**t up. It's so offensive. It's so offensive and condescending.

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I wonder if part of that is because our bodies are not well studied. They are not as well documented.

It's infuriating to me, the standard of health in America is a middle-aged white man. And it hasn't improved. We have studies showing that women are still not being included in trials. It's dangerous. When they released Ambien, everything was great, and then women started having a lot of side effects, getting in to car crashes, and they found out that women take longer to digest the medicine.

About like 75% of people who suffer from chronic pain are women. But the tests are done overwhelmingly on male mice. There's even a mice patriarchy. My favorite example is heart disease, because we really think of that as a male disease, and it's actually one of the leading killers of women in America, and black women especially. We imagine heart attacks as a man holding his chest like this dramatic heart attack in a movie, but women experience it really differently. We get nauseous, we get pain in our necks. If you have in pain in your neck and if you're 55 and older, you're actually seven times more likely in America to be dismissed from the hospital mid-heart attack.

Tara Robinson works for the American Heart Association now. She's an advocate for them. She had three heart attacks in 48 hours, and the third time she went to the hospital, she was like, "I am not leaving." They kept sending her home like, "You're fine." Then she was like, "You don't understand the pain that I am in."

You also talk about violence in the book. Violence is a health issue. I am constantly amazed, when we talk about healthcare, that we talk almost exclusively about sickness.

We never ever think about violence against women. It is a healthcare issue. They're calling it the shadow pandemic, because obviously it's just skyrocketing. Everything we do to isolate for COVID, self isolation, social isolation, lockdown . . . Imagine for a woman in a domestic violence situation or in an abusive relationship. Those stories stayed with me the most. Some nights I just couldn't go to sleep because it just made me think that there's such a gendered impact of COVID. It's also how intimately women experience the pandemic. So intimately, you couldn't even imagine.

I just can't imagine being beaten, abused, then isolated from your family. Wherever you go in the world, still it's happening. Domestic violence, forget that it's not being treated as a health issue. We still don't think that it's an issue that should be public. I feel like that silence is the biggest thing. We don't see it as a health issue, but also people are still hesitant to get involved.

Women are scared to ask for help. One woman I interviewed was like, "I was so scared," because any time she coughed or anything, her abuser would get really, really mad. He wouldn't let her out of the house. She was so scared that he was either going to kick her out or he was going to beat her to death. At the peak of lockdown, people thought that if you were just out on the street, you would die. There was a period where people were just not leaving their house.

A big thing around violence is more women have to say it. It is a health issue because the people who are killed the most in America through domestic violence are women and pregnant women.

I interviewed Shannon Watts from Moms Demand Gun Action, and she said what makes it so dangerous in America, more than any other country, is the access to guns. At one point in the pandemic, when they started opening things up, guns were deemed essential businesses. Gun stores opened up. I still can't believe that. And then of course these men are already under financial stress of the pandemic. They're buying guns, they're going home, taking it on their victims, on their partners. So many experts also said in the book that they're seeing more extreme wounds in domestic violence victims during COVID. Gun wounds, cigarette burns, all these things. It's a health issue, and we need to say that. We need to say that more.

Violence doesn't exist in its own lane. We think of violence as existing purely within the legal system and the judicial system and the justice system. We don't discuss it as within the medical system.

And violence against women, domestic violence, even rape, even today, is seen as the woman's fault. Rape culture is real. And what is rape culture? Every time I say this, people think I'm talking about like a culture that endorses rape. That's not what it is. Rape culture is when we blame women for men's sexual violence. We still do it. We might not say, "What were you wearing?" anymore, but we'll be like, "Oh, she was drunk." Or, you know, this, "What did you do to put yourself in that situation?" And women do this, too.

That's another thing that the book calls for. It's a cultural shift that we need. And one of the most radical proposals in the book is, can we believe women? Believe women.

You discuss in the book a new Marshall Plan. Tell me what that means.

Reshma Saujani, who founded Girls Who Code, has a whole movement around it, The Marshall Plan for Moms. We should give moms like $2,400. We should build back moms until they can rejoin the workplace. They can be at home, but they need money. 875,000 moms left the workforce summer of 2020.

America's fallback is women, unpaid labor, overworked women. The moms are not okay, and nobody gives a s__t. No one is coming to save us. It's crazy. We're burned out. We're overworked. It's going on and on. And nobody cares. It's so traumatic, and people don't realize what we're going through. I was just thinking about how we keep framing this in the news as a pandemic of the unvaccinated. Well, what about these kids? We're all like, "Oh, we have a vaccine for everyone," but it doesn't include the youngest children and pregnant women. Who are we? I just think it's crazy that nobody wants to know about it. And it's the moms' problem. Can you imagine what it's like when you know you can't protect your child, and then they get sick? I feel like it's because America doesn't value caretaking, and everything is falling on unpaid labor of women.

Meanwhile, we're getting sick.

That's another thing. Women's health is not an enigma. Where the F is the research? We have the money, we have the resources. Look at the controversy around insurance coverage for birth control and whatnot. We won't even get in to abortion. But do you know that insurance covers Viagra? Penis pumps?

There's the idea that our bodies are public property and are up for discussion, which is why then when we enter a healthcare situation, of course we feel disempowered. Of course we don't feel any agency, because we're used to having people who have opinions about our bodies tell us those opinions all the time.

All the time. Without bringing the whole abortion thing in, but just look what's happening with abortion. In the year 2022 It might be overturned. How is this happening in America? In the '60s and '70s, what were women saying? We can't be free without reproductive freedom. Reproductive justice. Reproductive control. Now it's happening again.

What really bothers me is that America was so instrumental in bringing these choices to women around the world. The UN Conference on Population and Development in the 1990's, initially started out very racist about population control. How did they intervene? They were like, "Oh, if you give women access to contraceptives and high paying jobs, guess what? They don't want to have 10, 12 kids and die by the time they're 20. They will actually choose to have smaller families themselves. Everybody benefits." We already have the data on this, and America's going to go backwards.

Tell me what we can do as patients in those dynamics that we are dealing with. How do we have that agency for ourselves as patients? We have to change ourselves.

We can change ourselves. The default now is not believing women, immediately. So I just ask to flip that. Just give her the benefit of the doubt and see where we go. That's the cultural shift that I'm asking for. Not only to believe women, but believing women of color who really have even less credibility. The other thing, and I really hate recommending this, but apparently it's very effective. Even Maya Dusenbery in her book "Doing Harm" said — women have said that when they bring in a male friend with them. The doctor is more likely to believe you. I wanted to say, bring a girlfriend with you, bring somebody with you. But apparently if he has a penis, it's more effective.

Because people, not just men, but women, hear men's voices.

And also do a lot of research. I think we also expect doctors to be magicians. Now you can be like, "No, this is my blood work. This is my family history." Research the provider. Read the reviews. Just like for everything else, when you're prepared and you've done your homework, you're more confident. You can ask more informed questions, and everybody benefits.

Something happened with my dad's endocrinologist, where he was like, "Oh, I don't know the answer to that." He had to do a little Google, too. I never thought about how hard it is for doctors to say, "I don't know." I don't think they're allowed to say that or encouraged to ever say that, and that freaks everybody out. But it's been happening a lot in the pandemic because nobody knows. We're all learning. I never even thought about that, because they just have so much power.